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California Health Benefit Exchange Design Options

October 27, 2011

Diana Dooley, Chair
California Health Benefit Exchange

Kimberly Belshé, Board Member
California Health Benefit Exchange

Paul Fearer, Board Member
California Health Benefit Exchange

Susan Kennedy, Board Member
California Health Benefit Exchange

Dr. Bob Ross, Board Member
California Health Benefit Exchange

Peter Lee, Executive Director
California Health Benefit Exchange

Pat Powers
California Health Benefit Exchange

Dear Exchange Board Members and Staff:

Consumers Union, the advocacy division of Consumer Reports, writes to offer some suggestions regarding the Design Options IT Procurement Solicitation presented to the Board on October 21, 2011. We understand that the solicitation simply sets the framework for the parameters bidders will follow, rather than establishing a design for eligibility and enrollment. But since the framework itself is so important, we urge inclusion of certain requirements from relevant Federal law and Guidance. In particular, we suggest that the IT Solicitation include a more comprehensive list of “Core Functionalities” than appeared in the PowerPoint presentation to the Board, as required by HHS through statute, regulations and guidance. While what we describe below may be implicit in your thinking about terms of the solicitation, we provide the citations to portions of the Guidance that we believe it would be beneficial to incorporate explicitly so bidders have a clear sense of state and federal expectations.

The Department of Health and Human Services and CMS issued Version 2.0 of its “Guidance for Exchange and Medicaid Information Technology (IT) Systems,” in May 2011 (hereinafter “IT Guidance” or “The Guidance”).[1] The Guidance, which supports and amplifies the Affordable Care Act (ACA) and proposed/final regulations, was created to “assist states as they design, develop, implement and operate technology and systems projects”[2] related to the Exchange, Medicaid, CHIP, premium tax credits and cost sharing reductions under the ACA. As stated in the Guidance document, [i]t is envisioned that the Health Insurance Exchange core functions, as well as the eligibility and enrollment functions for tax credits, Medicaid, and CHIP, will be governed using this IT Guidance… [it] will not supplant or override statutory or regulatory direction or requirements established by the Secretary of [HHS].”[3]

Alongside the statute, the Guidance sets out assumptions and goals for State IT roadmaps,[4] which include providing:

  • A high level of service, support and ease of use;
  • A similar experience regardless of source or amount of financial assistance someone may qualify for;
  • Ability to easily explore information on health coverage options and quickly and accurately enroll individuals in coverage;
  • A common or shared eligibility system, including integration of systems, programs and administration;
  • Support from a federal data services hub; and
  • A system that is able to generate data in support of performance management, public transparency, policy analysis, program integrity, and program evaluation.[5]

Significant ACA implementation leading up to 2014 is underway in California and Consumers Union understands that the State needs to provide an option to IT experts that allows them to build a system from components of what already exists in California, rather than a whole new system. Regardless of whether it is an entirely new system, one that combines new and existing components, or one that simply adapts what already is in place, there is a set of Core Functionalities that the IT system must address in order to meet Federal standards.

The vision for an eligibility system articulated in the IT Guidance would allow an individual to apply for coverage through multiple channels; all of the channels would then connect to a standardized, web-based system to evaluate eligibility for the Exchange, Medicaid, CHIP and the Basic Health Plan (optional).[6] Verifications to validate accuracy of information would be managed in a “standardized” way [emphasis added], including through the federal data services hub. In the future HHS will supply business rules that will allow resolution of discrepancies through automation.

The vision, as articulated in the IT Guidance, would allow people to complete an application and receive a placement within 15 to 20 minutes.[7] Recognizing that not everyone will be equipped to avail themselves of an entirely automated system, the IT Guidance emphasizes the importance of building in capacity for education and assistance online.

The Core Functionalities, as presented to the Board, identified many of the necessary functions required to establish and implement a streamlined eligibility system. A number of additional functionalities required by HHS need to be added to the State’s list, including:

  • Ability to connect to Federal Data Services Hub: An important component needed to conduct eligibility determinations is the use of the federal data services hub, which will provide support to states to deliver information about applicants’ income and immigration status. It is vital that any IT solicitation ensure that the designs proposed account for interface with the federal data hub, as well as any additional state data match systems;
  • Ability to generate data for a broad list of functions: the staff PowerPoint listed “reporting” as a “Core” functionality. While the capacity to report data is essential to the system, the IT infrastructure will be required to generate data in support of a number of responsibilities, not just for reporting purposes. The list of areas that will require data generation include “performance management, public transparency, policy analysis, program integrity and program evaluation;”[8]
  • Accessibility: Guidance 2.0 requires that the IT eligibility and enrollment system be designed to “meet the diverse needs of users without barriers or diminished function or quality” – such as for persons with disabilities, including those who use assistive technologies – and must provide “meaningful access by persons with limited English proficiency ;”[9]
  • Privacy and Security: Guidance 2.0 requires the State to “implement adequate privacy and security protections of the information,” particularly individual identifiable information and/or protected health information (PHI), including adoption of HIPAA and National Information Exchange Model (NIEM) standards and any state laws that impose additional restrictions; [10]
  • Adherence to identified architectural principles: Guidance 2.0 establishes principles created to “ensure that systems communicate effectively and efficiently with each other and also provide the extra measure of speed, knowledge management and agility demanded by today’s competitive environments.”[11] Of key importance to the core functionality are issues with “system performance,” including inter-operability, requiring that the IT system have the ability to:
    • Ensure quality, integrity, accuracy and usefulness of functionality and information;
    • Provide timely information transaction processing, including maximizing real-time determinations and decisions; and
    • Ensure systems are highly available and respond in a timely manner to customer requests.[12]

We know time is short for the State to design an effective and efficient IT system that satisfies federal requirements and utilizes the systems already in place in California. Federal Guidance recognizes that in addition to the IT requirements, personal help (inperson and on-phone) will also be required in many cases. Consumers Union has undertaken research that reviews some online systems in other states and a few California counties, and looked at how some of the problems inherent with online applications can be resolved through public enrollment stations accompanied by targeted live support. Our paper summarizing this research will be published in the next week. While not directly on point to the design option solicitation conversation, some of what we have uncovered would be useful information to have when considering what the State wants in an IT system. We will forward the paper along to all of you, as well as some of the underlying research, to aid your efforts to create the most successful eligibility and enrollment system possible as you move forward to meet 2014 goals.

Meanwhile, we would be happy to discuss in more detail any of our concerns or suggestions with staff or the Board. As you know, Consumers Union looks forward to continuing to work actively and productively with the Exchange Board and staff in the coming years to make and keep California a leader in ACA implementation.


Julie Silas

cc: David Maxwell-Jolly, Under Secretary, CA Department of Health & Human Services

[1]DHHS and CMS, “Guidance for Exchange and Medicaid Information Technology (IT) Systems,” Version 2.0, May 2011 < http://www.cms.gov/Medicaid-Information-Technology-MIT/Downloads/exchangemedicaiditguidance.pdf>.
[2]Guidance 2.0, page 1.
[3]Guidance 2.0, page 3.
[4]Guidance 2.0, pages 3 and 4.
[5]Guidance 2.0, page 4.
[6]Guidance 2.0, page 4.
[7]Guidance 2.0, page 5. [8]Guidance 2.0, pages 4 and 13.
[9]Guidance 2.0, page 9.
[10]Guidance 2.0, pages 8, 9 and 10.
[11]Guidance 2.0, pages 10 and 11.
[12]Guidance 2.0, page 14.